Corporate Medical Policy - Blue Cross NC
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Corporate Medical Policy
Vestibular Function Testing
File Name: vestibular_function_testing
Origination: 5/2017
Last CAP Review: 2/2020
Next CAP Review: 2/2021
Last Review: 2/2020
Description of Procedure or Service
Dizziness, vertigo, and balance impairments can arise from a loss of vestibular function. A
number of established laboratory-based tests are used to evaluate whether the symptoms are due
to dysfunction of the semicircular canals. These tests are based on the vestibulo-ocular reflex,
which is an involuntary movement of the eyes (nystagmus) in response to vestibular stimulation.
Established laboratory tests include electronystagmography (ENG) and videonystagmography
(VNG) test batteries, caloric stimulation, and rotational chair testing. Vestibular evoked
myogenic potentials (VEMPs), triggered by sound and vibration, are also being evaluated for the
diagnosis of otolith dysfunction.
VERTIGO
The vestibular system is an important component in balance control. It includes 5 end organs, 3
semicircular canals sensitive to head rotations, and 2 otolith organs (saccule, utricle) that sense
gravity and straight-line (forward, backward, left, right, downward or upward) accelerations.
Vertigo is the primary symptom of vestibular dysfunction. It can be experienced as illusory
movements such as spinning, swaying, or tilting. Vertigo may be associated with a feeling of
being pushed or pulled to the ground, blurred vision, nausea and vomiting, or postural and gait
instability. Vertigo may arise from damage or dysfunction of the vestibular labyrinth, vestibular
nerve, or central vestibular structures in the brainstem.
Vertigo may be caused by loose particles (otoconia) from the otolith organs that pass into one of
the semicircular canals, most frequently the posterior canal. Specific head movements cause the
particle to stimulate the canal, causing brief benign paroxysmal positional vertigo (BPPV).
Diagnosis
Brief BPPV can usually be diagnosed clinically based on history of positional vertigo, response
to the Dix-Hallpike maneuver or lateral roll tests, and resolution of symptoms with canal
repositioning maneuvers.
If vertigo cannot be attributed to BPPV based on history, symptoms, or response to the standard
maneuvers, a number of laboratory-based tests can be used to determine whether the vertigo is
due to loss of vestibular function. These tests are based on the vestibulo-ocular reflex, which is
an involuntary beating movement of the eyes (nystagmus) in response to vestibular stimulation.
Nystagmus induced by these tests can help to distinguish between central and peripheral
etiologies, in addition to determining whether the deficit is unilateral or bilateral. The typical
tests include the electronystagmography (ENG) or videonystagmography (VNG) test batteries,
caloric testing, and rotational chair testing.
ENG/VNG Test Batteries
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An Independent Licensee of the Blue Cross and Blue Shield AssociationVestibular Function Testing
The ENG/VNG test batteries include oculomotor evaluation and positional testing. ENG uses
electrodes at the canthus of the eyes to detect nystagmus while VNG uses infrared video
monitoring with goggles to measure nystagmus.
Caloric Testing
Caloric testing evaluates unilateral vestibular function. In the caloric test, warm or cold water or
warm or cold air, is introduced into each of the external ear canals. In some descriptions, caloric
testing is conducted as part of ENG/VNG test batteries.
Rotational Chair Testing
The rotational chair test evaluates bilateral vestibular function. Rotational chair devices include a
lightproof booth, computer-driven chair with a head restraint that rotates around a vertical axis,
ENG recording, an infrared camera, and a 2-way communication system. Typically, the chair is
rotated in 4 different patterns, constant acceleration followed by deceleration, rotating followed
by a rapid stop, rotating at progressively increasing velocities, and alternating directions.
Passive rotational testing without a rotational chair may be performed when the rotational chair is
not available. For the head impulse test, the patient is instructed to keep his or her eyes on a
target. The examiner then turns the head rapidly by about 15 °. With passive whole body testing
the examiner rotates the whole body to the rhythm of a metronome.
Vestibular Evoked Myogenic Potential Testing
Vestibular evoked myogenic potential (VEMP) tests are newer techniques that use loud sound
(e.g., click, tone burst) or bone vibration (e.g., tendon hammer tap to the forehead or mastoid) to
assess otolith function. Both the saccule and utricle are sensitive to sound as well as vibration
and movement.
Cervical VEMPs (cVEMPS) are measured by surface electrodes on the ipsilateral
sternocleidomastoid (SCM) muscle in the neck and are thought to originate primarily in the
saccule. Abnormality in any part of the auditory cVEMP pathway (saccule, inferior vestibular
nerve, vestibular nucleus, medial vestibulospinal tract, the accessory nucleus, the eleventh nerve,
SCM) can affect the response.
Ocular VEMPs (oVEMPs) detect subtle activity of an extraocular muscle using surface electrodes
under the contralateral eye during an upward gaze, and are thought to be due primarily to
stimulation of the utricle. The vestibulo-ocular reflex stimulated by sound or vibration is very
small, but synchronous bursts of activity of the extraocular muscles can be detected by
electromyography. Lesions that affect the oVEMP may occur in the utricle, superior vestibular
nerve, vestibular nucleus, and the crossed vestibulo-ocular reflex pathways.
Dynamic Posturography
Dynamic posturography may also be used to evaluate balance. Dynamic posturography is
discussed in a separate policy.
Treatment
The central vestibular system is able to compensate for loss of peripheral vestibular function.
Thus, the primary therapy for peripheral vestibular dysfunction is exercise-based and includes
exercises to promote gaze stability, habituate symptoms, and improve balance and gait.
Medications such as vestibular suppressants or antiemetics may be used in the acute stage but are
not recommended for chronic use. For patients who have recurrent symptoms uncontrolled by
other methods, a surgical or ablative approach may be used. The objective of the ablative
approach is to stabilize the deficit to allow central compensation.
REGULATORY STATUS
Vestibular analysis devices are currently regulated by the Food and Drug Administration (FDA)
through the 510(k) pathway. The term “vestibular analysis devices” includes both diagnostic
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An Independent Licensee of the Blue Cross and Blue Shield AssociationVestibular Function Testing
devices (e.g., rotary chairs, multiaxial chairs) and therapeutic devices (e.g., balance training and
balance rehabilitation devices). Some devices indicated for diagnostic testing include:
• ICS Impulse® (Otometrics, 2013)
• Sway Balance™ (Sway Medical [Capacity Sports], 2012)
• Nydiag 200 Rotary Chair (Interacoustics A/S, 2010)
• Epley Omniax ® (Vesticon, 2008)
• VMT System (Target Health, 1998)
• VORTEQ ™ (Vestibular Ocular Reflex Test Equipment, Micromedical Technologies,
1989)
• RVT-50 Rotary Chair for Vestibular Testing (ICS Medical, 1987)
• EquiTest® (Natus Medical [NeuroCom International], 1985)
• Chair, Vestibular, Rotary, Computerized (Contraves, 1978)
An example of equipment used for vestibular evoked myogenic potentials is the Bio-Logic Nav-
Pro (Bio-logic Systems Corp), which in 2003 was cleared for marketing by FDA through the
510(k) process for use in recording and displaying human physiologic data, and for auditory
screening and assisting in evaluation of auditory and hearing-related disorders using auditory
brainstem responses recorded from electroencephalography electrodes placed on the scalp.
***Note: This Medical Policy is complex and technical. For questions concerning the technical
language and/or specific clinical indications for its use, please consult your physician.
Policy
BCBSNC will provide coverage for vestibular function testing when it is determined to be
medically necessary because the medical criteria and guidelines noted below are met.
Benefits Application
This medical policy relates only to the services or supplies described herein. Please refer to the
Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit
design; therefore member benefit language should be reviewed before applying the terms of this
medical policy.
When Vestibular Function Testing is covered
Vestibular function testing using electronystagmography and videonystagmography testing
batteries, caloric testing, or rotational chair testing may be considered medically necessary when
the following conditions have been met:
• The patient has symptoms of a vestibular disorder (e.g., dizziness, vertigo, imbalance);
AND
• A clinical evaluation, including maneuvers such as the Dix-Hallpike test if indicated, has
failed to identify the cause of the symptoms.
When Vestibular Function Testing is not covered
Vestibular evoked myogenic potential tests are considered investigational.
Vestibular function testing for the assessment of typical benign paroxysmal positional vertigo
that can be diagnosed clinically is not medically necessary.
Repeat vestibular function testing when treatment resolves symptoms is not medically
necessary.
Vestibular function testing in all other situations is investigational.
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An Independent Licensee of the Blue Cross and Blue Shield AssociationVestibular Function Testing
All other laboratory-based vestibular function tests not described above are considered
investigational.
Policy Guidelines
For individuals who have a suspected vestibular disorder not clinically diagnosed as benign
paroxysmal positional vertigo who receive ENG/VNG test batteries, caloric testing, or rotational
chair testing, the evidence includes technology assessments of a large body of literature. Relevant
outcomes are test accuracy, symptoms, functional outcomes, and quality of life. Based on review
of controlled studies, caloric testing was given a level A recommendation that this test was
predictive of loss of vestibular function. Based on a prospective study assessing a narrow
spectrum of patients with the suspected vestibular dysfunction and a well-designed retrospective
study, which included a criterion standard test, rotational chair testing was also given a level A
recommendation. These tests are both considered criterion standard tests of vestibular function.
ENG/VNG test batteries, which may include caloric testing, are also established methods of
assessing loss of vestibular function. The evidence is sufficient to determine that the technology
results in a meaningful improvement in the net health outcome.
For individuals who have a suspected vestibular disorder not clinically diagnosed as benign
paroxysmal positional vertigo who receive VEMP testing, the evidence includes mainly
association studies. Relevant outcomes are test accuracy, symptoms, functional outcomes, and
quality of life. There is a large and rapidly growing literature on VEMP tests for the assessment
of otolith function, although most studies have assessed how the cervical VEMP and ocular
VEMP change with various disease states. Studies on diagnostic accuracy and clinical utility of
this technique for evaluating otolith organs and central pathways are needed in the appropriate
populations. The evidence is insufficient to determine the effects of the technology on health
outcomes.
For individuals who have clinically diagnosed benign paroxysmal positional vertigo (BPPV) with
typical presentation who receive laboratory-based vestibular function testing, the evidence
includes technology assessments and practice guidelines. Relevant outcomes are test accuracy,
symptoms, functional outcomes, and quality of life. BPPV with a typical presentation can be
diagnosed clinically based on history, the Dix-Hallpike maneuver, lateral roll test, and canalith
repositioning procedures; thus, laboratory-based vestibular function testing does not add
diagnostic information in such routine cases. The evidence is sufficient to determine that the
technology is unlikely to improve the net health outcome.
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that
it will be reimbursed. For further information on reimbursement guidelines, please see Administrative
Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed
in the Category Search on the Medical Policy search page.
CODING
The following codes may be used for evaluation of vestibular function under electronystagmography
(ENG) and videonystagmography (VNG) testing batteries, caloric testing, rotational chair, and
vestibular evoked myogenic potential (VEMP) testing.
ENG/VNG Testing Batteries
The ENG/VNG testing batteries may include caloric testing, positional tests, and oculomotor
evaluation (i.e., spontaneous nystagmus including gaze-evoked nystagmus, positional nystagmus,
optokinetic nystagmus, smooth pursuit tracking, saccade test).
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An Independent Licensee of the Blue Cross and Blue Shield AssociationVestibular Function Testing
The following codes may be used: 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, and
92547.
Vestibular Evoked Myogenic Potential Testing: 92517, 92518, 92519.
Vestibular Evoked Myogenic Potential Testing may be coded using 92700.
ICD-10: A88.1, H81.01 – H82.9, and R42.
BCBSNC may request medical records for determination of medical necessity. When medical records are
requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless
all specific information needed to make a medical necessity determination is included.
Scientific Background and Reference Sources
BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.104, 3/9/2017
BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.104, 2/8/2018
Specialty Matched Consultant Advisory Panel 2/2018
Specialty Matched Consultant Advisory Panel 2/2019
BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.104, 2/14/2019
Specialty Matched Consultant Advisory Panel 2/2020
BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.104, 2/13/2020
Policy Implementation/Update Information
5/26/17 New policy developed. Vestibular function testing with electronystagography/
videonystagmography, caloric test, and rotational chair test for suspected vestibular
dysfunction is considered medically necessary when criteria are met. Vestibular
evoked myogenic potentials are considered investigational. Vestibular function testing
for benign paroxysmal positional vertigo is not medically necessary. Notification given
5/26/2017 for effective date 7/28/2017. (sk)
7/13/18 Reference added. Specialty Matched Consultant Advisory Panel review 2/28/2018.
(sk)
7/16/19 Specialty Matched Consultant Advisory Panel review 2/20/2019. Reference added.
(sk)
6/30/20 Specialty Matched Consultant Advisory Panel review 2/19/2020. (sk)
12/31/20 Reference added. New codes 92517, 92518, and 92519 added to Billing/Coding section
effective 1/1/2021. (sk)
Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are
determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and
subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational
purposes only and is based on research of current medical literature and review of common medical practices in the treatment
and diagnosis of disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review
and revise its medical policies periodically.
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